Concussions in Football

Jeffrey Kachmann, MD

James Keszei

Topics Covered

1. What is a Concussion;

2. Symptoms/Signs of a Concussion;

3. Research on Long Term Effects of Concussions;

4. Second Impact Syndrome (video);

5. How to Deal with Concussions, When in Doubt, Sit it Out (video);

6. Athlete Responsibilities.

7. Return To Play Guidelines

8. Discussion/Questions/Comments (VIDEO)

What is a Concussion?

A concussion is caused when there is a jarring or shaking that causes a a rapid onset of brief disruption of brain function. Research has indicated that concussions of youth brains can occur at much higher rate as compared to fully developed adult brains. It is VERY important to realize that it DOES NOT require a blow to the head to cause a concussion! Any acceleration/deceleration or twisting/rotational injury to the body can transmit to the brain. It is a GLOBAL brain injury. Concussions cause real injury to brain tissue.

Youth brains react differently, more unpredictably when concussed, whichis one of the main reasons why it is so important to recognize signs of concussions and have the athlete sit out until symptom free, while at rest and during exertion. Rotational forces result in more brain injury than blunt trauma.

Initial Evaluation

The suspected head injured athlete exam should always begin with basic life support-ONFIELD-particularly with a loss of consciousness-LOC, neurologic symptoms, or spinal pain

Airway-check the airway and note obstructions

Breathing- breathing rate and pattern, skin/nailbed color

Circulation-pulse rate and rhythm, nailbed color

Spine-palpate the entire spine for tenderness or irregularities

LOC/Concussion evaluation

Symptoms of a ConcussionThe Center for Disease Control (CDC) has provided the following signs and symptoms of a concussion:

OBSERVATIONS OF COACHES, PARENTS, ATHLETIC TRAINERS

1. Appears dazed and stunned;2. Is confused about assignment or position;3. Forgets instructions;4. Is unsure of game, score or opponent;5. Moves clumsily;6. Answers questions slowly;7. Loses consciousness (even briefly);8. Shows behavior or personality changes;9. Can’t recall events prior to hit or fall;10.Can’t recall events after a hit or fall.

“WHEN IN DOUBT, SIT ‘EM OUT”

1. Headache or “pressure” in head2. Nausea and/or vomiting3. Balance problems or dizziness4. Double or blurred vision5. Sensitivity to light6. Sensitivity to noise or ringing in ears7. Feeling sluggish, hazy, foggy or groggy8. Concentration or memory problems9. Confusion10. Does not “feel right”11. Neck Pain12. More irritable or emotional

“WHEN IN DOUBT, SIT ‘EM OUT!”

SYMPTOMS REPORTED BY ATHLETE

WHAT SHOULD I DO??

Any athlete suspected of having a concussion must be removed from play and evaluated by a trained professional knowledgeable about

concussions:

Trainer/TherapistNurse/NP/PA

Doc

Have someone reliable frequently observe and assess the child for at least 24-72 hours or until all signs and symptoms resolve

Make sure you have a SCAT card available

THE SCAT CARD

Name: ___________________________ Date __________Sport/Team: _______________________ Mouth guard? YN1) SIGNSWas there loss of consciousness or unresponsiveness? Y NWas there seizure or convulsive activity? Y NWas there a balance problem / unsteadiness? Y N2) MEMORYModified Maddocks questions (check correct)At what venue are we? __; Which half is it? __; Who scored last?__What team did we play last? __; Did we win last game? __?3) SYMPTOM SCORETotal number of positive symptoms (from reverse side of the card) = ______

SCAT CARD, COT’D 4) COGNITIVE ASSESSMENT

5 word recall Immediate Delayed

(Examples) (after concentration tasks)

Word 1 _____________ cat ___ ___

Word 2_____________ pen ___ ___

Word 3 _____________ shoe ___ ___

Word 4 _____________ book ___ ___

Word 5 _____________ car ___ ___

Months in reverse order:

Jun-May-Apr-Mar-Feb-Jan-Dec-Nov-Oct-Sep-Aug-Jul (circle incorrect)

or

Digits backwards (check correct)

5-2-8 3-9-1 ______

6-2-9-4 4-3-7-1 ______

8-3-2-7-9 1-4-9-3-6 ______

7-3-9-1-4-2 5-1-8-4-6-8 ______

Ask delayed 5-word recall now

SCAT CARD, COT’D

5) NEUROLOGIC SCREENINGPass FailSpeech ___ ___Eye Motion and Pupils ___ ___Pronator Drift ___ ___Gait Assessment ___ ___Any neurologic screening abnormality necessitates formal neurological evaluation by a trained professional

Concussion Treatment

First recognize the concussion by onfield, sideline, or ER evalClose observation 24-72 hours minimum—check pupil size , consciousness, movements, ability to think and functionFollow RTP-Return To Play- guidelines strictlyRest--Non stimulating environment for a week or until all symptoms cease-NO TV, IPOD, Video Games, Reading, Computers, Loud Noise, Bright LightsTylenol as neededNo alcohol or illicit drugsFrequent evaluations by trainer, medical professionalOne percent require emergent surgeriesTake to the hospital if ever in doubt!

Send your player to the Hospital if:

Headaches worsenToo drowsy to wake upCan’t Recognize people or places or very confusedRepetitive vomiting—more than once!SeizuresExtremity or facial numbness, tingling, pain or weaknessSlurred speechUnsteady walkDilated Pupils or unequal gazeIrregular, slow, or very fast pulse or breathingAny obvious injuriesLOC (loss of consciousness) more than 5 minutes

Head Injuries can cause structural injury in and around the brain

NEVER forget that a seemingly simple hit resulting in a concussion can cause a:

skull fracture epi or subdural hematoma (blood clot on the outside or inside of the lining around the brain) post traumatic subarachnoid hemorrhage (salt n pepper bleeding on the brain surface) intracerebral hemorrhage (bleeding inside the brain-petecchial or larger clot) brain contusion (bruise) axonal shearing injury (nerve fiber or coating injury)Brainstem injuryMalignant out of control brain swelling resulting in death or disabilitySpinal injury (VIDEO)

SECOND IMPACT SYNDROME

One of the worst scenarios involving concussions occurs when a youth athlete is concussed during an event, returns to play, and receives a second concussion on top of the existing concussion. In this scenario, and athlete can suffer a traumatic brain injury that can debilitate the youth athlete for the rest of their life, or even result in their death. Particularly in children, a concussion can result in loss of autoregulation of brain blood flow with a rush of blood into the brain blood vessels causing very rapid brain swelling and herniation through the skull and instant death or severe debilty. I have personally witnessed this and it is very scary!

WHEN IN DOUBT, SIT ‘EM OUT!

Brain Vulnerability After a Concussion

The brain is VERY vulnerable to further injury after a concussion for minutes to daysLarge numbers of neurons (nerve cells) can die as a result of even small changes in intracranial (inside the head) pressure, blood flow, and anoxia (lack of oxygen—always remember the ABC’s of resuscitation!!!) after a concussion

REMEMBER, CONCUSSIONS ARE VERY GROSSLY UNDERDIAGNOSED—UP TO 88% ARE UNRECOGNIZED!!!

REPEATS

Athletes involved in a concussion are far more vulnerable to further concussions

(VIDEO)

Research on Long Term Effects of Concussions

New research regarding the long term effects of repeated concussions can cause some athletes to suffer the progressive neurodegenerative brain disease Chronic Traumatic Encephalopathy (CTE), which eventually leads to dementia.

An estimated 10% to 20% of all athletes participating in contact sports suffer a concussion each season. Most athletes recover completely and can return to play following an appropriate period of recovery. Realize that cumulative concussions injure the brain permanently and cause long term effects now and later in life.

CTE

Healthy >

CTE >

Long Term effects from Concussions

Memory lossCognitive disorders (problems thinking through things)DementiaDepressionAnxietyPTSD-Post Traumatic Stress DisorderSubstance abusePoor Physical PerformanceLack of energy or enthusiasmIrritabiltyHeadachesDizzinessInsomniaTremors/Parkinsonism—Muhammad Ali

OUCH!

How to Deal With a Suspected Concussion

The most important thing to remember when dealing with an athlete with a suspected concussion is to air on the side of caution. It is not worth the potentiallong term health problems, or traumatic brain injury, to rush an athlete back intoa game or practice situation, prior to being symptom free at rest and during exertion.

*****WHEN IN DOUBT, SIT THEM OUT*****

Review your league’s concussion policy to ensure the safety of the players is thenumber one priority.

Return to play policy. Many leagues, to include Youth, Middle School, and HighSchool programs do NOT have a return to play policy, which could result in catastrophic injury coupled with legal action.

Athlete Responsibilities

As Coaches you must let athletes know they will not be looked down uponor treated unfairly if they report a concussion. Athletes must feel confidentthey can report symptoms of a concussion without Coaches punishing them for not “Toughing it Out”. Most Athletes are very competitive, however, they are responsible for reporting symptoms and need to understand the potentiallong term negative effects of not reporting concussions.

www.sportslegacy.orgMinimum Recommended GuidelinesAs a natural evolution of the 10 Point Plan, in September 2010, SLI announced the release of 7 Steps for Brain Safety: Minimum Recommended Guidelines for Youth Sports, a list of practical, simple, and free solutions to minimize brain trauma.On the following pages, you will find a link to recommended programs, as well as links to supplemental programs. Programs should adopt at least the recommended program.If you received a paper version of the 7 Steps, visit www.sportslegacy.org to locate the links.SLI’s 7 Steps for Brain Safety1. Preseason Education for Coaches2. Preseason Education for Athletes3. Preseason Education for Parents4. Coaches Use CDC’s Heads Up Clipboard Sticker5. Adopt CDC’s Concussion Action Plan for Removaland Return-to-Play6. Prevention through Neck Strengthening7. Prevention through Overall Brain Trauma Reduction

Concussion Return To Play Guidelines

SYMPTOMS GRADE 1ST 2ND 3RD

***RTP time begins after completely asymptomatic

<15 MIN/NO PTA* 1 RTP OK 20 min RTP in 2 wk End season/OK next yr

PTA<30MIN/NO LOC** 1 RTP 1 week RTP 3-4wks End season/OK next yr

PTA>30MIN<24HR/LOC<5MIN

2 RTP 1 week RTP 1 mo or End season/OK next yr

end season

*PTA=post trauma amnesia **LOC=loss of consciousness ***RTP=return to play

Concussion RTP Guidelines, Cont’d

SYMPTOMS GRADE 1ST 2ND 3Rd

PTA>24HR/LOC>5MIN 3 RTP 4-6MO END SEASON OR END SEASON

**STRONGLY CONSIDER TRANSPORT TO HOSPITAL ER FOR EVAL W GRADE 3 CONCUSSIONS**

Graduated Return to Play**Athlete MUST be asymptomatic at REST and after EXERTION

No activity for ONE WEEK after injury and asymptomaticCleared to return by trainer/medical professionalComponent scores of ImPact test normal

Gradual daily increase in activity as follows unless symptoms recur—if they recur wait 24 hrs and start progressions from day one again:

Light aerobic exercise—walk/slow jog/stationary bike, etc—no resistance training

Sport specific activity—throwing/kicking a ball, etcNon contact training drills with resistance trainingFull contact training drillsReturn to sport without restriction

REMEMBER

Always use certified headgear in practice and game playMake extra sure it fits and is secureCheck air bladders and padding each and every time of useUse properly fitting mouthpieces at all timesUse IMPACT or equivalent testingUse a SPECT card or equivalent sideline testWHEN IN DOUBT SIT ‘EM OUT!

Discussion

Questions

Comments